Radiation therapy practice changes in the COVID‐19 pandemic era: A pilot study in California

Abstract Purpose This study aims to investigate practice changes among Southern and Northern California's radiation oncology centers during the COVID‐19 pandemic. Methods On the online survey platform SurveyMonkey, we designed 10 survey questions to measure changes in various aspects of medical physics practice. The questions covered patient load and travel rules; scopes to work from home; new protocols to reduce corona virus disease‐2019 (COVID‐19) infection risk; availability of telemedicine; and changes in fractionation schedules and/or type of treatment plans. We emailed the survey to radiation oncology centers throughout Northern and Southern California, requesting one completed survey per center. All responses were anonymized, and data were analyzed using both qualitative and quantitative research methods. Results At the end of a 4‐month collection period (July 2, 2021 to October 11, 2021), we received a total of 61 responses throughout Southern and Northern California. On average, 4111 patients were treated per day across the 61 centers. New COVID‐19‐related department and hospital policies, along with hybrid workflow changes, infectious control policies, and changes in patient load have been reported. Results also showed changes in treatment methods during the pandemic, such as increased use of telemedicine, hypofractionation for palliative, breast cancer, and prostate cancer cases; and simultaneous boosts, compared to sequential boosts. Conclusion Our California radiation oncology center population study shows changes in various aspects of radiation oncology practices during the COVID‐19 pandemic. This study serves as a pilot study to identify possible correlations and new strategies that allow radiation oncology centers to continue providing quality patient care while ensuring the safety of both staff and patients.


INTRODUCTION
anecdotal experience of individual radiation center's practices in response to COVID-19. Previous articles 1,2 discussed practical suggestions for the radiotherapeutic management of the most frequent cancer during the COVID-19 era. A joint ESTRO-ASTRO 1 strongly recommended stereotactic body radiotherapy (SBRT) for lung cancer treatment. The COVID-19 pandemic Breast Cancer Consortium 2 has strongly recommended moderate hypofractionated schemes to reduce treatment duration and patients' exposure and stated that when an extra dose to the tumor bed is clinically intended, it should preferably be simultaneous and integrated. While previous research articles shared a series of lessons learned and suggestions for other radiation oncology departments to consider when treating cancer patients during the pandemic era, it is desirable to examine comprehensively how different radiation oncology centers have pivoted in response to the pandemic.
To this end, we performed a pilot study to measure the practice changes during the COVID-19 pandemic among a cohort of 61 of California's radiation oncology centers. This paper discusses changes in patient load experienced during the pandemic, along with adjustments in workflow infrastructure regarding onsite and offsite work. This study reveals the most important changes in infection control policies, work models, and patient treatment methods implemented by the centers to mitigate the unprecedented impact of the COVID-19 pandemic.

MATERIALS AND METHODS
The online survey platform SurveyMonkey was used to generate a 10-question survey, which allowed us to gather data from a large pool of respondents easily and conveniently. The 10 survey questions were designed to assess the impact of the COVID-19 pandemic on changes in patient load and travel rules; permission and scope to work from home (WFH); new procedures and protocols implemented to reduce COVID-19 infection risk; availability of telemedicine, and changes in fractionation schedules and/or type of treatment plans. We emailed the survey to medical physicists throughout California, requesting that only one medical physicist per facility complete the survey. Our data collection period spanned 4 months, ranging from July 2, 2021, to October 11, 2021. A total of 61 responses were collected at the end of our collection period. All responses were anonymized, and data were analyzed using both qualitative and quantitative research methods.

RESULTS
At the end of the 4-month collection period, we received 36 respondents from Southern California and  Table 2 also indicated how these California's radiation oncology centers experienced shifts in patient load due to the pandemic. During our collection period, 52 centers (85.3%) reported that their centers experienced similar patient load as before the pandemic; four (6.5%) centers experienced a decreased patient load as before the pandemic; and five (8.2%) centers experienced an increased patient load, compared to before the pandemic.

Accommodation of remote working mode
Results show close to half of 61 radiation oncology centers suspended travel for employees (52.5%), while the other half did not (47.5%; Table 3). The majority of centers (83.3%) reported using telemedicine during the pandemic, while 16.7% reported not using it. About 90.0% of these centers allowed employees to WFH at least partially. Survey data also show (see Figure 1) the percentages of groups of employees who were allowed to WFH at least partially. Our results show that 56.3% of clerical and billing employees, 83.6% of medical dosimetrists, 85.5% of medical physicists, 10.9% of nurses, and 58.2% of radiation oncologists among our 61 centers were allowed to WFH at least partially.

Departmental policy changes
Our qualitative data outline the most important department changes indicated by our respondents. We classified practice changes during the COVID-19 pandemic era into three categories: new COVID-19-related department policies, new hybrid work models, and new changes in patient treatment methods. In the TA B L E 2 Differences in patient load during the pandemic experienced by 61 radiation oncology centers in California

DISCUSSION
Our California study population averaged a total of 4111 patients treated per day, with each center experiencing different fluctuations in patient load during the pandemic. In order for these centers to continue providing high-quality radiotherapy to a large volume of cancer patients while keeping employees and patients safe, many centers implemented new infection control policies and changes in patient treatment methods. There are increases in hypofractionation of palliative, breast cancer, and prostate cancer cases and increased use of more hypofractionation and simultaneous integrated boost, compared to sequential boosts. Our findings provide both qualitative and quantitative insight into how the pandemic has changed practices among 61 of California's radiation oncology centers.   (Table 3), over 50% of team members were allowed to WFH at least partially (excluding the category of nurses; Figure 1). Our results may allude to a new direction of integrating WFH into our workflow permanently, and these results provide alternative practice options for radiation oncology centers in the endemic era. Radiation treatment, conventionally considered as one of the personnel-intensive treatment modalities with the engagement of technical staff, physicists, and physicians, may be amicable to remote working while maintaining high-quality patient care, with the advancement of technology and communication.

CONCLUSION
Despite the many disruptions to personal and professional life brought on by the pandemic, COVID-19 has also created an opportunity for the field of radiation oncology to evaluate our current clinical workflow, safety policies, and patient treatment methods. Although many changes were necessitated by quickly pivoting in response to COVID-19, these changes may be unanticipated improvements that further modernize our field. It also presented a unique opportunity for medical centers to explore alternative practice options and the feasibility of potentially more effective ways of oper-ation in the endemic era. Our California chapter survey serves as a pilot study to identify possible correlations and change strategies. As the pandemic and its various consequences continue to shape how our radiation oncology centers operate, it is critical to continue investigating to identify, validate, and analyze modifications in response to the pandemic. An extension to a national survey is being planned to verify such changes with the possibility to further reveal demographic-dependent factors.